Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-013-2728-0
HIP
Intra-articular adhesions following hip arthroscopy: a risk factor analysis S. Clifton Willimon • Karen K. Briggs Marc J. Philippon
•
Received: 23 July 2013 / Accepted: 12 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose The purpose of this study was to evaluate possible risk factors for symptomatic adhesions after hip arthroscopy. Methods Data were analysed from hip arthroscopies performed between 2005 and 2009. Only primary hip arthroscopies were included. Data collected included demographics, primary treatment, rehabilitation, revision surgery, and presence of adhesions at revision. Results One thousand two hundred and sixty-four hips in patients 18 years or older underwent primary hip arthroscopy during the defined period. Eight underwent revision hip arthroscopy by a different surgeon. Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not [95 % CI 1.1–8.2]. Patients who did not receive circumduction therapy were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises [95 % CI 1.25–11.0]. Conclusion Risk factors for adhesions following hip arthroscopy identified were age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction. Level of evidence IV. Keywords FAI
Hip arthroscopy Revision Adhesions
S. C. Willimon K. K. Briggs M. J. Philippon (&) Steadman Philippon Research Institute, 181 W. Meadow Dr. Suite 1000, Vail, CO 81657, USA e-mail: [email protected] K. K. Briggs e-mail: [email protected]
Introduction Hip arthroscopy is progressing rapidly, both in technique and in the literature, and it has become an established treatment for intra-articular pathologies such as CAM and pincer femoroacetabular impingement (FAI) [9, 10, 13, 16, 17], chondral injuries [15], labral tears [5, 9, 10], ligamentum teres injuries [4], as well as extra-articular injuries such as abductor tendon tears [18], trochanteric bursitis, and iliopsoas tendinopathy [19]. Surgical techniques have advanced greatly in the last 10 years from diagnostic and debridement applications to much more complex procedures [5, 11]. These advanced techniques also create additional sources of intra-operative and postoperative complications [2, 6]. Intra-articular hip adhesions have recently been recognized as a significant source of failure and postoperative pain following both open and arthroscopic surgery for FAI [1, 2, 7, 8, 14]. Risk factors for the development of intraarticular hip adhesions following surgical treatment of FAI have not been established in the literature. To decrease revision rates due to adhesions, risk factors for adhesions must be identified to develop prevention strategies. The hypothesis of this study was that preoperative factors, such as range of motion, surgical factors, such as number of surfaces requiring osteoplasty, and postoperative rehabilitation regimen would be risk factors for symptomatic adhesions following hip arthroscopy.
Materials and methods Data from arthroscopic hip surgeries performed between 2005 and 2009 were identified from a prospectively collected database. The study included only primary hip
123
Knee Surg Sports Traumatol Arthrosc
arthroscopies performed by the senior author and patients 18 years or older. Revision hip arthroscopy was defined as patients who returned to the senior author for symptoms requiring another arthroscopy or patients reporting a second hip arthroscopy by another surgeon. Patients were excluded if they had previous hip surgery. In addition to demographic information, BMI, type of injury, and time from injury to surgery were collected. On radiographic analysis, the centre edge angle and alpha angle were measured. Previous studies have shown both measurements to have good-to-excellent intra- and interreliability [12]. On physical examination, range of motion, FABER distance test (measuring the distance of the lateral knee to the exam table when the limb is in flexionabduction-external rotation), impingement test, and hip dial test were performed and recorded. At primary surgery, type of labral treatment (debridement, repair, reconstruction), type of impingement treatment (neck osteoplasty and/or rim trimming), and treatment of cartilage injuries (chondroplasty, microfracture) were recorded. In addition, associated procedures including capsular plication, iliopsoas lengthening, synovectomy, as well as the number of anchors used for labral repair were documented. At revision surgery, the presence of adhesions was recorded. A change in the rehabilitation protocol was implemented at a specific time point during the study. Hip circumduction was added to the rehabilitation protocol. This was added by the senior author for early mobility to provide an optimal environment in and around the joint on the assumption that it would reduce the risk of scar tissue. Circumduction was performed at 70 degrees of hip flexion and at neutral hip flexion. This study was IRB (Institutional Review Board) approved by the Vail Valley Medical Center IRB, number 2002-03. Statistical analysis Descriptive statistics (arithmetic mean, standard deviation, range) were calculated using standard formulae. Comparisons between categorical variables (i.e. presence of adhesions, gender) were performed using the chi-square test. All continuous variables demonstrated significant departure from normal distribution with substantial skew (Kolmogorov–Smirnov test for normality: p \ 0.001). Therefore, nonparametric univariate analysis was performed with the Mann–Whitney U test for two group comparisons and the Kruskal–Wallis ANOVA for multiple group comparisons. Continuous variables were dichotomized to calculate odds ratios. Odds ratios and 95 % confidence intervals were calculated using standard formulae. Binary logistic regression analysis was done to identify variables that were independently predictive of
123
second surgery with adhesions. Statistical analysis was performed with SPSS (version 11.0, SPSS Inc., Chicago, IL) software package.
Results One thousand three hundred ninety-two patients met the inclusion criteria. From this group, 1,272 (91 %) patients had completed at least a 1-year follow-up or were contacted and could report a revision arthroscopy. Of the 1,272 hips, 8 patients had revision surgeries elsewhere. These were not included in the study because detailed information on their subsequent surgery was not available. Of the remaining 1,264 hips, 57 (4.5 %) had repeat arthroscopies by the same surgeon. All repeat hip arthroscopies had adhesions. Patients were significantly younger in the adhesions group (Table 1). Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Alpha angle was the only radiographic factor related to adhesions (Table 2). Patients with Modified Harris Hip score less than 50 were 2.4 times more likely to be in the adhesion group [95 % CI 1.4–4.3] (Table 3). The only surgical factor related to adhesion risk was microfracture at the time of primary arthroscopy (Table 4). Seven percent of hips with adhesions underwent microfracture versus 18 % of hips without adhesions underwent microfracture. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not undergo microfracture [95 % CI 1.1–8.2]. In November 2008, the hip rehabilitation program was changed to include hip circumduction. Seven per cent of the adhesion group participated in circumduction therapy compared to 23 % of the non-adhesion group (p = 0.002). Patients who did not participate in circumduction exercises Table 1 Demographics of the adhesion and non-adhesion groups Adhesions
No adhesions
N
57
1,207
Age (range)
32 (SD = 11)
36 (SD = 13)
p value
0.005
Gender (males/females)
50 %:50 %
60 %:40 %
n.s.
Traumatic injury
24 %
21 %
n.s.
BMI
24 (SD = 4)
24.3 (SD = 4)
n.s.
Time from primary to revision hip arthroscopy
16.1 months (SD = 10)
Revision within 1 year
44 %
Revision between 1 and 2 years
44 %
SD standard deviation
Knee Surg Sports Traumatol Arthrosc Table 2 Radiographic and physical examination findings in the adhesion and non-adhesion groups
N
Adhesions
No adhesions
57
1,207
p value
Table 5 Binary logistic regression model for independent predictors of adhesions Variable
(B)
95 % Confidence interval
p value
No circumduction
4.2
1.3–13.9
0.017
Positive dial test
30 %
29 %
n.s.
Age under 30
2.7
1.5–4.8
0.001
FABER Distance Difference Flexion
3.7
2.7
n.s.
MHHS under 50
2.0
1.1–3.6
0.033
116 (SD = 13)
118 (SD = 34)
n.s.
Dependent variable was need for revision surgery for adhesions (yes/no)
Abduction
47 (SD = 14)
48 (SD = 12)
n.s.
Adduction
23 (SD = 8)
22 (SD = 9)
n.s.
External Rotation
47 (SD = 20)
44 (SD = 20)
n.s.
Internal Rotation
26 (SD = 14)
27 (SD = 15)
n.s.
Alpha angle
65 (SD = 15)
70 (SD = 14)
0.033
Alpha angle less than 55 degrees
30 %
17 %
0.01
Centre edge angle
36 (SD = 9)
35 (SD = 7)
n.s.
SD standard deviation
Table 3 Patient-derived outcome scores at the time of revision for the adhesion and non-adhesion groups Adhesions
No adhesions
p value
Modified Harris hip score
59 (SD = 16)
63 (SD = 22)
n.s.
Modified Harris hip score less than 50 points
32 %
20 %
0.027
SF-12 physical component score
40 (SD = 9.8)
43 (SD = 9.6)
n.s.
SF-12 mental component score
56 (SD = 7.6)
53 (SD = 9.5)
n.s.
SD standard deviation Table 4 Findings and treatments at the time of revision arthroscopy in the adhesions and non-adhesion groups Adhesions
No adhesions
p value
N
57
1,207
Labral Repair
57 %
88 %
n.s.
Microfracture
7%
18 %
0.025
Ligamentum teres tear
64 %
64 %
n.s.
Adhesion at initial procedure Presence of synovitis at initial procedure
6% 77 %
5% 83 %
n.s. n.s.
Pincer/CAM/Combined
7 %: 7 %:86 %
6 %: 14 %:80 %
n.s.
Number of anchors used
3
3
n.s.
Iliopsoas lengthening
3%
5%
n.s.
were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises (95 % CI 1.25–11.0).
Logistic regression analysis showed circumduction, age under 30, and MHHS less than 50 points was the predictor of revision surgery for symptomatic adhesions (Table 5).
Discussion The most important finding of the present study was that the addition of circumduction exercises following hip arthroscopy reduced the prevalence of adhesions requiring revision arthroscopy. This study provides analysis of potential risk factors for hip adhesions following hip arthroscopy, a significant cause of surgical failure and need for revision surgery [2, 6, 7, 13]. This information may help the clinician inform the patient of their risk of adhesions. Furthermore, with the addition of circumduction exercises, the risk of adhesions may be decreased. Circumduction exercises played a critical role in minimizing the risk of adhesion formation. In November 2008, the postoperative rehabilitation protocol was modified to include circumduction exercises performed passively 3 times daily, which resulted in a precipitous reduction in the revision arthroscopy rate. The results showed a 4.1-fold increased risk of adhesions in patients who did not perform circumduction therapy. An additional factor that showed a decrease in risk for adhesions was undergoing microfracture for contained full thickness chondral defects. The decreased risk of adhesions following microfracture may be attributed to the difference in rehabilitation regimen of patients receiving microfracture versus those who did not. Patients undergoing microfracture are prescribed continuous passive motion (CPM) machines for a total of 6 weeks instead of 2 weeks postoperatively for those patients who do not undergo microfracture. Additionally, patients who underwent microfracture were protected with crutches for 7–8 weeks (9.1 kg flat foot) compared to 3–4 weeks (9.1 kg flat foot) of crutch use in patients in who did not undergo microfracture. This increased exposure to passive joint motion and extended protection from joint loading may contribute to decreased adhesion formation. Treatment of labral tears whether with debridement (not currently used for treatment of labral tears), repair, or
123
Knee Surg Sports Traumatol Arthrosc
reconstruction showed no difference in risk for adhesions. Additionally, femoral osteoplasty (CAM treatment), acetabular rim resection (pincer treatment), or combined CAM and pincer treatment did not increase adhesion risk. This finding was not expected as most adhesions occur at the site of the neck osteoplasty or labral repair which was hypothesized to be related to exposed bony surfaces. Other operative factors such as number of anchors used, iliopsoas lengthening, and presence of synovitis, all of which could theoretically increase intra-articular inflammation, played no role in this population. Limitations of this study include all cases coming from one referral centre. These results may not apply to all hip arthroscopic series. Also, all patients underwent a defined rehabilitation program following initial arthroscopy which may be different from other practices. This study is also limited by the fact that not all patients returned for examination. Some patients may have symptomatic adhesions, but do not return or they may be addressed through physical therapy. Another possible limitation was that patients had other pathologies besides adhesions. It is unclear whether the adhesion was a result of further injury or whether the other findings were due to adhesions. This may lead to underestimation of the adhesion rate since some patients may have adhesions but no other painful pathology. More research is needed on the effect of capsulolabral or femoral neck adhesions on the repaired hip joint.
Conclusions Risk factors for adhesions following hip arthroscopy were identified age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction. Adhesions following hip arthroscopy were reduced with changes to rehabilitation protocol. Acknowledgments One or more authors have received research support, not directly related to this study, from the following companies: Smith & Nephew, Arthrex, Siemens, and Ossur.
References 1. Aprato A, Jayasekera N, Villar RN (2013) Revision hip arthroscopic surgery: outcome at three years. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2373-7 2. Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC (2013) Why do hip arthroscopy procedures fail? Clin Orthop Relat Res 471:2523–2529
123
3. Byrd JW, Jones KS (2009) Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up. Arthroscopy 25:365–368 4. Byrd JW, Jones KS (2004) Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 20:385–391 5. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK (2013) Acetabular labral reconstruction with an iliotibial band autograft: outcome and survivorship analysis at minimum 3-year follow-up. Am J Sports Med 41:1750–1756 6. Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR Jr, Bush-Joseph CA, Nho SJ (2013) Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthroscopy 29:589–595 7. Heyworth BE, Shindle MK, Voos JE, Rudzki JR, Kelly BT (2007) Radiologic and intraoperative findings in revision hip arthroscopy. Arthroscopy 23:1295–1302 8. Krueger A, Leunig M, Siebenrock KA, Beck M (2007) Hip arthroscopy after previous surgical hip dislocation for femoroacetabular impingement. Arthroscopy 23(1285–1289):e1 9. Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH (2013) Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: a prospective randomized study. Arthroscopy 29:46–53 10. Larson CM, Giveans MR, Stone RM (2012) Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up. Am J Sports Med 40:1015–1021 11. Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS (2009) Advanced techniques in hip arthroscopy. Instr Course Lect 58:423–436 12. Mast NH, Impellizzeri F, Keller S, Leunig M (2011) Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res 469:188–199 13. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA (2009) Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br 91:16–23 14. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ (2007) Revision hip arthroscopy. Am J Sports Med 35:1918–1921 15. Philippon MJ, Schenker ML, Briggs KK, Maxwell RB (2008) Can microfracture produce repair tissue in acetabular chondral defects? Arthroscopy 24:46–50 16. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ (2010) Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med 38:99–104 17. Shindle MK, Voos JE, Nho SJ, Heyworth BE, Kelly BT (2008) Arthroscopic management of labral tears in the hip. J Bone Joint Surg Am 90(Suppl 4):2–19 18. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT (2009) Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 37:743–747 19. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT (2007) Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip. Arthroscopy 23:1246e1–1246e5
HIP
Intra-articular adhesions following hip arthroscopy: a risk factor analysis S. Clifton Willimon • Karen K. Briggs Marc J. Philippon
•
Received: 23 July 2013 / Accepted: 12 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose The purpose of this study was to evaluate possible risk factors for symptomatic adhesions after hip arthroscopy. Methods Data were analysed from hip arthroscopies performed between 2005 and 2009. Only primary hip arthroscopies were included. Data collected included demographics, primary treatment, rehabilitation, revision surgery, and presence of adhesions at revision. Results One thousand two hundred and sixty-four hips in patients 18 years or older underwent primary hip arthroscopy during the defined period. Eight underwent revision hip arthroscopy by a different surgeon. Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not [95 % CI 1.1–8.2]. Patients who did not receive circumduction therapy were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises [95 % CI 1.25–11.0]. Conclusion Risk factors for adhesions following hip arthroscopy identified were age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction. Level of evidence IV. Keywords FAI
Hip arthroscopy Revision Adhesions
S. C. Willimon K. K. Briggs M. J. Philippon (&) Steadman Philippon Research Institute, 181 W. Meadow Dr. Suite 1000, Vail, CO 81657, USA e-mail: [email protected] K. K. Briggs e-mail: [email protected]
Introduction Hip arthroscopy is progressing rapidly, both in technique and in the literature, and it has become an established treatment for intra-articular pathologies such as CAM and pincer femoroacetabular impingement (FAI) [9, 10, 13, 16, 17], chondral injuries [15], labral tears [5, 9, 10], ligamentum teres injuries [4], as well as extra-articular injuries such as abductor tendon tears [18], trochanteric bursitis, and iliopsoas tendinopathy [19]. Surgical techniques have advanced greatly in the last 10 years from diagnostic and debridement applications to much more complex procedures [5, 11]. These advanced techniques also create additional sources of intra-operative and postoperative complications [2, 6]. Intra-articular hip adhesions have recently been recognized as a significant source of failure and postoperative pain following both open and arthroscopic surgery for FAI [1, 2, 7, 8, 14]. Risk factors for the development of intraarticular hip adhesions following surgical treatment of FAI have not been established in the literature. To decrease revision rates due to adhesions, risk factors for adhesions must be identified to develop prevention strategies. The hypothesis of this study was that preoperative factors, such as range of motion, surgical factors, such as number of surfaces requiring osteoplasty, and postoperative rehabilitation regimen would be risk factors for symptomatic adhesions following hip arthroscopy.
Materials and methods Data from arthroscopic hip surgeries performed between 2005 and 2009 were identified from a prospectively collected database. The study included only primary hip
123
Knee Surg Sports Traumatol Arthrosc
arthroscopies performed by the senior author and patients 18 years or older. Revision hip arthroscopy was defined as patients who returned to the senior author for symptoms requiring another arthroscopy or patients reporting a second hip arthroscopy by another surgeon. Patients were excluded if they had previous hip surgery. In addition to demographic information, BMI, type of injury, and time from injury to surgery were collected. On radiographic analysis, the centre edge angle and alpha angle were measured. Previous studies have shown both measurements to have good-to-excellent intra- and interreliability [12]. On physical examination, range of motion, FABER distance test (measuring the distance of the lateral knee to the exam table when the limb is in flexionabduction-external rotation), impingement test, and hip dial test were performed and recorded. At primary surgery, type of labral treatment (debridement, repair, reconstruction), type of impingement treatment (neck osteoplasty and/or rim trimming), and treatment of cartilage injuries (chondroplasty, microfracture) were recorded. In addition, associated procedures including capsular plication, iliopsoas lengthening, synovectomy, as well as the number of anchors used for labral repair were documented. At revision surgery, the presence of adhesions was recorded. A change in the rehabilitation protocol was implemented at a specific time point during the study. Hip circumduction was added to the rehabilitation protocol. This was added by the senior author for early mobility to provide an optimal environment in and around the joint on the assumption that it would reduce the risk of scar tissue. Circumduction was performed at 70 degrees of hip flexion and at neutral hip flexion. This study was IRB (Institutional Review Board) approved by the Vail Valley Medical Center IRB, number 2002-03. Statistical analysis Descriptive statistics (arithmetic mean, standard deviation, range) were calculated using standard formulae. Comparisons between categorical variables (i.e. presence of adhesions, gender) were performed using the chi-square test. All continuous variables demonstrated significant departure from normal distribution with substantial skew (Kolmogorov–Smirnov test for normality: p \ 0.001). Therefore, nonparametric univariate analysis was performed with the Mann–Whitney U test for two group comparisons and the Kruskal–Wallis ANOVA for multiple group comparisons. Continuous variables were dichotomized to calculate odds ratios. Odds ratios and 95 % confidence intervals were calculated using standard formulae. Binary logistic regression analysis was done to identify variables that were independently predictive of
123
second surgery with adhesions. Statistical analysis was performed with SPSS (version 11.0, SPSS Inc., Chicago, IL) software package.
Results One thousand three hundred ninety-two patients met the inclusion criteria. From this group, 1,272 (91 %) patients had completed at least a 1-year follow-up or were contacted and could report a revision arthroscopy. Of the 1,272 hips, 8 patients had revision surgeries elsewhere. These were not included in the study because detailed information on their subsequent surgery was not available. Of the remaining 1,264 hips, 57 (4.5 %) had repeat arthroscopies by the same surgeon. All repeat hip arthroscopies had adhesions. Patients were significantly younger in the adhesions group (Table 1). Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Alpha angle was the only radiographic factor related to adhesions (Table 2). Patients with Modified Harris Hip score less than 50 were 2.4 times more likely to be in the adhesion group [95 % CI 1.4–4.3] (Table 3). The only surgical factor related to adhesion risk was microfracture at the time of primary arthroscopy (Table 4). Seven percent of hips with adhesions underwent microfracture versus 18 % of hips without adhesions underwent microfracture. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not undergo microfracture [95 % CI 1.1–8.2]. In November 2008, the hip rehabilitation program was changed to include hip circumduction. Seven per cent of the adhesion group participated in circumduction therapy compared to 23 % of the non-adhesion group (p = 0.002). Patients who did not participate in circumduction exercises Table 1 Demographics of the adhesion and non-adhesion groups Adhesions
No adhesions
N
57
1,207
Age (range)
32 (SD = 11)
36 (SD = 13)
p value
0.005
Gender (males/females)
50 %:50 %
60 %:40 %
n.s.
Traumatic injury
24 %
21 %
n.s.
BMI
24 (SD = 4)
24.3 (SD = 4)
n.s.
Time from primary to revision hip arthroscopy
16.1 months (SD = 10)
Revision within 1 year
44 %
Revision between 1 and 2 years
44 %
SD standard deviation
Knee Surg Sports Traumatol Arthrosc Table 2 Radiographic and physical examination findings in the adhesion and non-adhesion groups
N
Adhesions
No adhesions
57
1,207
p value
Table 5 Binary logistic regression model for independent predictors of adhesions Variable
(B)
95 % Confidence interval
p value
No circumduction
4.2
1.3–13.9
0.017
Positive dial test
30 %
29 %
n.s.
Age under 30
2.7
1.5–4.8
0.001
FABER Distance Difference Flexion
3.7
2.7
n.s.
MHHS under 50
2.0
1.1–3.6
0.033
116 (SD = 13)
118 (SD = 34)
n.s.
Dependent variable was need for revision surgery for adhesions (yes/no)
Abduction
47 (SD = 14)
48 (SD = 12)
n.s.
Adduction
23 (SD = 8)
22 (SD = 9)
n.s.
External Rotation
47 (SD = 20)
44 (SD = 20)
n.s.
Internal Rotation
26 (SD = 14)
27 (SD = 15)
n.s.
Alpha angle
65 (SD = 15)
70 (SD = 14)
0.033
Alpha angle less than 55 degrees
30 %
17 %
0.01
Centre edge angle
36 (SD = 9)
35 (SD = 7)
n.s.
SD standard deviation
Table 3 Patient-derived outcome scores at the time of revision for the adhesion and non-adhesion groups Adhesions
No adhesions
p value
Modified Harris hip score
59 (SD = 16)
63 (SD = 22)
n.s.
Modified Harris hip score less than 50 points
32 %
20 %
0.027
SF-12 physical component score
40 (SD = 9.8)
43 (SD = 9.6)
n.s.
SF-12 mental component score
56 (SD = 7.6)
53 (SD = 9.5)
n.s.
SD standard deviation Table 4 Findings and treatments at the time of revision arthroscopy in the adhesions and non-adhesion groups Adhesions
No adhesions
p value
N
57
1,207
Labral Repair
57 %
88 %
n.s.
Microfracture
7%
18 %
0.025
Ligamentum teres tear
64 %
64 %
n.s.
Adhesion at initial procedure Presence of synovitis at initial procedure
6% 77 %
5% 83 %
n.s. n.s.
Pincer/CAM/Combined
7 %: 7 %:86 %
6 %: 14 %:80 %
n.s.
Number of anchors used
3
3
n.s.
Iliopsoas lengthening
3%
5%
n.s.
were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises (95 % CI 1.25–11.0).
Logistic regression analysis showed circumduction, age under 30, and MHHS less than 50 points was the predictor of revision surgery for symptomatic adhesions (Table 5).
Discussion The most important finding of the present study was that the addition of circumduction exercises following hip arthroscopy reduced the prevalence of adhesions requiring revision arthroscopy. This study provides analysis of potential risk factors for hip adhesions following hip arthroscopy, a significant cause of surgical failure and need for revision surgery [2, 6, 7, 13]. This information may help the clinician inform the patient of their risk of adhesions. Furthermore, with the addition of circumduction exercises, the risk of adhesions may be decreased. Circumduction exercises played a critical role in minimizing the risk of adhesion formation. In November 2008, the postoperative rehabilitation protocol was modified to include circumduction exercises performed passively 3 times daily, which resulted in a precipitous reduction in the revision arthroscopy rate. The results showed a 4.1-fold increased risk of adhesions in patients who did not perform circumduction therapy. An additional factor that showed a decrease in risk for adhesions was undergoing microfracture for contained full thickness chondral defects. The decreased risk of adhesions following microfracture may be attributed to the difference in rehabilitation regimen of patients receiving microfracture versus those who did not. Patients undergoing microfracture are prescribed continuous passive motion (CPM) machines for a total of 6 weeks instead of 2 weeks postoperatively for those patients who do not undergo microfracture. Additionally, patients who underwent microfracture were protected with crutches for 7–8 weeks (9.1 kg flat foot) compared to 3–4 weeks (9.1 kg flat foot) of crutch use in patients in who did not undergo microfracture. This increased exposure to passive joint motion and extended protection from joint loading may contribute to decreased adhesion formation. Treatment of labral tears whether with debridement (not currently used for treatment of labral tears), repair, or
123
Knee Surg Sports Traumatol Arthrosc
reconstruction showed no difference in risk for adhesions. Additionally, femoral osteoplasty (CAM treatment), acetabular rim resection (pincer treatment), or combined CAM and pincer treatment did not increase adhesion risk. This finding was not expected as most adhesions occur at the site of the neck osteoplasty or labral repair which was hypothesized to be related to exposed bony surfaces. Other operative factors such as number of anchors used, iliopsoas lengthening, and presence of synovitis, all of which could theoretically increase intra-articular inflammation, played no role in this population. Limitations of this study include all cases coming from one referral centre. These results may not apply to all hip arthroscopic series. Also, all patients underwent a defined rehabilitation program following initial arthroscopy which may be different from other practices. This study is also limited by the fact that not all patients returned for examination. Some patients may have symptomatic adhesions, but do not return or they may be addressed through physical therapy. Another possible limitation was that patients had other pathologies besides adhesions. It is unclear whether the adhesion was a result of further injury or whether the other findings were due to adhesions. This may lead to underestimation of the adhesion rate since some patients may have adhesions but no other painful pathology. More research is needed on the effect of capsulolabral or femoral neck adhesions on the repaired hip joint.
Conclusions Risk factors for adhesions following hip arthroscopy were identified age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction. Adhesions following hip arthroscopy were reduced with changes to rehabilitation protocol. Acknowledgments One or more authors have received research support, not directly related to this study, from the following companies: Smith & Nephew, Arthrex, Siemens, and Ossur.
References 1. Aprato A, Jayasekera N, Villar RN (2013) Revision hip arthroscopic surgery: outcome at three years. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2373-7 2. Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC (2013) Why do hip arthroscopy procedures fail? Clin Orthop Relat Res 471:2523–2529
123
3. Byrd JW, Jones KS (2009) Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up. Arthroscopy 25:365–368 4. Byrd JW, Jones KS (2004) Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 20:385–391 5. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK (2013) Acetabular labral reconstruction with an iliotibial band autograft: outcome and survivorship analysis at minimum 3-year follow-up. Am J Sports Med 41:1750–1756 6. Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR Jr, Bush-Joseph CA, Nho SJ (2013) Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthroscopy 29:589–595 7. Heyworth BE, Shindle MK, Voos JE, Rudzki JR, Kelly BT (2007) Radiologic and intraoperative findings in revision hip arthroscopy. Arthroscopy 23:1295–1302 8. Krueger A, Leunig M, Siebenrock KA, Beck M (2007) Hip arthroscopy after previous surgical hip dislocation for femoroacetabular impingement. Arthroscopy 23(1285–1289):e1 9. Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH (2013) Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: a prospective randomized study. Arthroscopy 29:46–53 10. Larson CM, Giveans MR, Stone RM (2012) Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up. Am J Sports Med 40:1015–1021 11. Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS (2009) Advanced techniques in hip arthroscopy. Instr Course Lect 58:423–436 12. Mast NH, Impellizzeri F, Keller S, Leunig M (2011) Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res 469:188–199 13. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA (2009) Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br 91:16–23 14. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ (2007) Revision hip arthroscopy. Am J Sports Med 35:1918–1921 15. Philippon MJ, Schenker ML, Briggs KK, Maxwell RB (2008) Can microfracture produce repair tissue in acetabular chondral defects? Arthroscopy 24:46–50 16. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ (2010) Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med 38:99–104 17. Shindle MK, Voos JE, Nho SJ, Heyworth BE, Kelly BT (2008) Arthroscopic management of labral tears in the hip. J Bone Joint Surg Am 90(Suppl 4):2–19 18. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT (2009) Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 37:743–747 19. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT (2007) Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip. Arthroscopy 23:1246e1–1246e5
